Social Services Coordinator Transitional Care Unit
DescriptionAll the benefits and perks you need for you and your family:
- Benefits from Day One - Paid Days Off from Day One - Student Loan Repayment Program - Career Development - Whole Person Wellbeing Resources - Mental Health Resources and Support - Pet Insurance - Debt-free Education (Certifications and Degrees without out-of-pocket tuition expense) Our promise to you:
Joining AdventHealth is about being part of something bigger.
It's about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit.
AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ.
Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team.
All while understanding that together we are even better.
Schedule:
Full Time Shift:
Days - M-F 9am-530pm with every other weekend on call The community you'll be caring for:
701 W PLYMOUTH AVE, Deland, FL 32720 The role you'll contribute:
The Social Services Coordinator is responsible for generating appropriate resident admissions and overseeing the admissions process.
In addition, this individual intervenes with patients who have complex psychosocial needs and require assistance with eligibility determination for social programs.
They will offer crisis intervention to patients and families with psychosocial needs and coordinate and facilitate the development of a discharge plan.
The value you'll bring to the team:
Referral and Admissions o Process all inquiries received by the facility.
o Conduct facility tours for prospective residents and/or their relatives.
o Provide education to residents and families regarding the services available at the facility and the resources that are provided to residents based on individual resident needs.
o Coordinates preadmission procedures, handouts, and required paperwork.
(A) Through pre-admission contacts, obtains assessment of the potential resident's needs, diagnosis, special equipment needs, services that will be needed, etc.
and informs the facility.
Interdisciplinary team of these needs to ensure a smooth admission process.
(B) Ensures all needed and required paperwork is completed timely.
o PASRR information and forms are completed prior to admission.
o An Attending Physician who will be responsible for the care of the resident after admission has been designated by the resident/family prior to admission.
Orders by the Physician are available on admission.
o Transfer information is complete with all needed information including copies of related tests, examination reports, etc.
to ensure continuity of care for the resident after admission.
o Identifies DNR status, copies of Living Wills and Health Care Proxy information at the time of admission to the facility.
o Ensures that admission to the facility is made only if the needs of the resident can be met by the facility per the admission criteria policy.
o Obtains resident financial data and pertinent information of Medicare status and coverage available to ensure admission are made with the resident's resources used as appropriate and to work as the advocate of the resident to ensure coverage that is available to the resident is utilized most appropriately.
o Obtains resident financial data and pertinent information of Medicare status and coverage available to ensure admission are made with the resident's resources used as appropriate and to work as the advocate of the resident to ensure coverage that is available to the resident is utilized most appropriately.
o Admission procedures in each department are coordinated by the Transitional Care Coordinator to ensure facility mission and policies are implemented in meeting new resident needs.
o Information on Resident Rights and how to apply and use Medicare and Medicaid benefits are prominently displayed in the facility and are reviewed at the time of admission with the resident/family as appropriate.
Documentation of this review is retained in the facility records.
o Coordinates the Admission process with the facility by assisting the resident, responsible party, and supportive others in the adjustment and orientation to the facility.
Psychosocial Assessment and Interventions o Ensures that all PASRRS are completed accurately and timely in coordination with the admissions department.
o Ensures timely documentation on each resident in the facility as required.
o Participates in each resident's plan of care meeting.
Oversees that resident/families are invited and informed of the meetings.
o On the basis of preliminary risk screening, assesses resident and family's psychosocial risk factors through evaluation of prior functioning levels, appropriateness and adequacy of support systems, reaction to illness and ability to cope o Intervenes with residents and families regarding emotional, social, and financial consequences of illness and/or disability; accesses and mobilizes family/community resources to meet identified needs o Serves as a resource person and provides information and intervention related to treatment decisions and end-of-life issues o Advocates for resident and their rights and family empowerment and independence to make autonomous health care decisions and access needed services within the health care system Discharge Planning o Acts as the Discharge Coordinator for the facility.
o Participates in discharge planning activities for residents in order to ensure a timely discharge and to provide appropriate linkage with post-discharge care providers o Deals with families exhibiting complex family dynamics that impact directly on resident care and discharge o Communicates with care coordinators regarding the discharge planning status of all residents referred by them.
o Screens, coordinates, and documents post-acute placement and service referrals.
Referrals will be made through electronic medical record (EMR) for determination of bed availability both in and out of local area including psychiatric services.
o Educates resident/family and physician regarding post-acute options and addresses issues of choice o Facilitates arranging and/or participates in resident/family conferences regarding plan of care and/or transitions of care o Participates in the quality assurance and performance improvement committee o Performs other duties as assignedQualificationsThe expertise and experiences you'll need to succeed:
REQUIRED:
o Bachelor's Degree in Social Work or a Human Services field including but not limited to Sociology, Special Education, Rehabilitation Counseling, and Psychology and minimum 2 years current experience as a Social Worker in a skilled nursing facility.
o In lieu of required bachelor's degree, an Associate degree and a minimum of 7 years' current experience as a Social Worker in a skilled nursing facility.
o Must be 18 years of age or older PREFERRED:
o Current degree as a Master-level (MSW) Social Worker in applicable state OR see licensure requirements.
This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.
Recommended Skills Crisis Intervention Diseases And Disorders Education Finance Health Care System Medicaid Estimated Salary: $20 to $28 per hour based on qualifications.
- Benefits from Day One - Paid Days Off from Day One - Student Loan Repayment Program - Career Development - Whole Person Wellbeing Resources - Mental Health Resources and Support - Pet Insurance - Debt-free Education (Certifications and Degrees without out-of-pocket tuition expense) Our promise to you:
Joining AdventHealth is about being part of something bigger.
It's about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit.
AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ.
Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team.
All while understanding that together we are even better.
Schedule:
Full Time Shift:
Days - M-F 9am-530pm with every other weekend on call The community you'll be caring for:
701 W PLYMOUTH AVE, Deland, FL 32720 The role you'll contribute:
The Social Services Coordinator is responsible for generating appropriate resident admissions and overseeing the admissions process.
In addition, this individual intervenes with patients who have complex psychosocial needs and require assistance with eligibility determination for social programs.
They will offer crisis intervention to patients and families with psychosocial needs and coordinate and facilitate the development of a discharge plan.
The value you'll bring to the team:
Referral and Admissions o Process all inquiries received by the facility.
o Conduct facility tours for prospective residents and/or their relatives.
o Provide education to residents and families regarding the services available at the facility and the resources that are provided to residents based on individual resident needs.
o Coordinates preadmission procedures, handouts, and required paperwork.
(A) Through pre-admission contacts, obtains assessment of the potential resident's needs, diagnosis, special equipment needs, services that will be needed, etc.
and informs the facility.
Interdisciplinary team of these needs to ensure a smooth admission process.
(B) Ensures all needed and required paperwork is completed timely.
o PASRR information and forms are completed prior to admission.
o An Attending Physician who will be responsible for the care of the resident after admission has been designated by the resident/family prior to admission.
Orders by the Physician are available on admission.
o Transfer information is complete with all needed information including copies of related tests, examination reports, etc.
to ensure continuity of care for the resident after admission.
o Identifies DNR status, copies of Living Wills and Health Care Proxy information at the time of admission to the facility.
o Ensures that admission to the facility is made only if the needs of the resident can be met by the facility per the admission criteria policy.
o Obtains resident financial data and pertinent information of Medicare status and coverage available to ensure admission are made with the resident's resources used as appropriate and to work as the advocate of the resident to ensure coverage that is available to the resident is utilized most appropriately.
o Obtains resident financial data and pertinent information of Medicare status and coverage available to ensure admission are made with the resident's resources used as appropriate and to work as the advocate of the resident to ensure coverage that is available to the resident is utilized most appropriately.
o Admission procedures in each department are coordinated by the Transitional Care Coordinator to ensure facility mission and policies are implemented in meeting new resident needs.
o Information on Resident Rights and how to apply and use Medicare and Medicaid benefits are prominently displayed in the facility and are reviewed at the time of admission with the resident/family as appropriate.
Documentation of this review is retained in the facility records.
o Coordinates the Admission process with the facility by assisting the resident, responsible party, and supportive others in the adjustment and orientation to the facility.
Psychosocial Assessment and Interventions o Ensures that all PASRRS are completed accurately and timely in coordination with the admissions department.
o Ensures timely documentation on each resident in the facility as required.
o Participates in each resident's plan of care meeting.
Oversees that resident/families are invited and informed of the meetings.
o On the basis of preliminary risk screening, assesses resident and family's psychosocial risk factors through evaluation of prior functioning levels, appropriateness and adequacy of support systems, reaction to illness and ability to cope o Intervenes with residents and families regarding emotional, social, and financial consequences of illness and/or disability; accesses and mobilizes family/community resources to meet identified needs o Serves as a resource person and provides information and intervention related to treatment decisions and end-of-life issues o Advocates for resident and their rights and family empowerment and independence to make autonomous health care decisions and access needed services within the health care system Discharge Planning o Acts as the Discharge Coordinator for the facility.
o Participates in discharge planning activities for residents in order to ensure a timely discharge and to provide appropriate linkage with post-discharge care providers o Deals with families exhibiting complex family dynamics that impact directly on resident care and discharge o Communicates with care coordinators regarding the discharge planning status of all residents referred by them.
o Screens, coordinates, and documents post-acute placement and service referrals.
Referrals will be made through electronic medical record (EMR) for determination of bed availability both in and out of local area including psychiatric services.
o Educates resident/family and physician regarding post-acute options and addresses issues of choice o Facilitates arranging and/or participates in resident/family conferences regarding plan of care and/or transitions of care o Participates in the quality assurance and performance improvement committee o Performs other duties as assignedQualificationsThe expertise and experiences you'll need to succeed:
REQUIRED:
o Bachelor's Degree in Social Work or a Human Services field including but not limited to Sociology, Special Education, Rehabilitation Counseling, and Psychology and minimum 2 years current experience as a Social Worker in a skilled nursing facility.
o In lieu of required bachelor's degree, an Associate degree and a minimum of 7 years' current experience as a Social Worker in a skilled nursing facility.
o Must be 18 years of age or older PREFERRED:
o Current degree as a Master-level (MSW) Social Worker in applicable state OR see licensure requirements.
This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.
Recommended Skills Crisis Intervention Diseases And Disorders Education Finance Health Care System Medicaid Estimated Salary: $20 to $28 per hour based on qualifications.
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